DISSOCIATIVE

DISORDERS
Dr Anila Sadaf
Key Features Of Dissociative
Disorders
 Dissociative
Dissociation
Disorders
 Some aspect of cognition or experience becomes inaccessible to consciousness
 Avoidance response

 Some types of dissociation are harmless and common (e.g., losing track of time)

Sudden disruption in the continuity of:

 Consciousness
 Emotions
 Motivation
 Memory
 Identity
 Dissociation and Memory
How does memory work under stress?
 Psychodynamic
 Traumatic events are repressed

 Cognitive
 Extreme stress usually enhances rather than impairs memory

 Interference memory formation

 Not accessible to awareness later
 Memory Deficits and
Dissociation
Memory deficits in explicit but not implicit memory
Explicit memory
 Involves conscious recall of experiences
 e.g., senior prom, mom’s birthday party

Implicit memory
 Underlies behaviors based on experiences that cannot be consciously recalled
 e.g., playing tennis, writing a check
 Memory Deficits and Dissociation
Distinguishing other causes of memory loss from dissociation:
 Dementia
 Memory fails slowly over time
 Is not linked to stress
 Accompanied by other cognitive deficits
 Inability to learn new information

 Memory loss after a brain injury

 Substance abuse
 Depersonalization/De-realization
Disorder
 Perception of self is altered
1. Triggered by stress or traumatic event
2. No disturbance in memory
3. No psychosis or loss of memory
4. Often comorbid with anxiety, depression
5. Typical onset in adolescence
6. Chronic course

 Symptoms are not explained by substances, another dissociative disorder, another

psychological disorder, or a medical condition
 DSM-5 CRITIERIA:
Depersonalization/Derealization Disorder
Experiences of depersonalization or detachment from one’s mental processes as if one is in a dream
 Unusual sensory experiences
 Limbs feel deformed or enlarged
 Voice sounds different or distant
 Feelings of detachment or disconnection
 Watching self from outside
 Floating above one’s body

Or experiences of derealization

 World has become unreal
 World appears strange, peculiar, foreign, dream-like
 Objects appear at times strangely diminished in size, at times flat
 Incapable of experiencing emotions
 Feeling as if they were dead, lifeless, mere automatons
 Experiences of unreality of surroundings
Symptoms are persistent or recurrent
Reality testing remains intact
Symptoms are not explained by substances, another dissociative disorder
 Depersonalization/Derealization Disorder

Symptoms

Persistent or recurrent experiences of feeling detached from one’s mental processes or body.

Depersonalization causes significant distress or impairment in social, occupational, or other functioning.

During the experience of depersonalization, reality testing remains intact, one is aware of his/her
experiences are unusual.

The depersonalization experience does not occur during the course of another mental disorder and is not
due to the physiological effects of a substance or a general medication.
 Duration And Intensity
 The mean age at onset of depersonalization/derealization disorder is 16 years, although the
disorder can start in early or middle childhood; a minority cannot recall ever not having had the
symptoms.

 Less than 20% of individuals experience onset after age 20 years and only 5% after age 25 years.
Onset in the fourth decade of life or later is highly unusual.

 Onset can range from extremely sudden to gradual. Duration of

depersonalization/derealization disorder episodes can vary greatly, from brief (hours or days) to
prolonged (weeks, months, or years).
 Risk Factors
1.Exposure to extreme child abuse and neglect
2.Genetics and family history
3.Previous history of mental illness and substance abuse
4.Stressful lifestyles. Being raised by emotionally troubled parents

Prognosis
Treating depersonalization disorder is challenging. Outpatient and Inpatient treatment programs for DD do have a
good track record of success, but they require hard work and dedication,
 Differential Diagnosis
Illness anxiety disorder. Although individuals with depersonalization/derealization disorder can
present with vague somatic complaints as well as fears of permanent brain damage, the diagnosis of
depersonalization/derealization disorder is characterized by the presence of a constellation of typical
depersonalization/derealization symptoms and the absence of other manifestations of illness anxiety
disorder.

Major depressive disorder. Feelings of numbness, deadness, apathy, and being in a dream are not
uncommon in major depressive episodes. However, in depersonalization/derealization disorder, such
symptoms are associated with further symptoms of the disorder.
Obsessive-compulsive disorder. Some individuals with depersonalization/derealization disorder can
become obsessively preoccupied with their subjective experience or develop rituals checking on the status
of their symptoms.

Anxiety disorders. Depersonalization/derealization is one of the symptoms of panic attacks, increasingly

common as panic attack severity increases. Therefore, depersonalization/dereahzation disorder should
not be diagnosed when the symptoms occur only during panic attacks that are part of panic disorder,
social anxiety disorder, or specific phobia.
 Comorbidity
In a convenience sample of adults recruited for a number of depersonalization research studies, lifetime
comorbidities were high for unipolar depressive disorder and for any anxiety disorder, with a significant
proportion of the sample having both disorders. Comorbidity with posttraumatic stress disorder was low.

The three most commonly co-occurring personality disorders were

avoidant, borderline, and obsessive-compulsive.
 DSM-5 CRITERIA FOR Dissociative
Amnesia
Inability to remember important personal information, usually of a traumatic or stressful nature,
that is too extensive to be ordinary forgetfulness

The amnesia is not explained by substances, or by other medical or psychological conditions

Specify dissociative fugue subtype if:

 the amnesia includes inability to recall one’s past, confusion about identity, or assumption of a new identity, and
 sudden, unexpected travel away from home or work

Usually remits spontaneously

 Dissociative Amnesia:
Dissociative Fugue Subtype
Amnesia and flight and new identity
 Latin fugere, “to flee”

Sudden, unexpected travel with inability to recall one’s past

 Assume new identity
 May involve new name, job, personality characteristics
 More often of brief duration
 Remits spontaneously
 Dissociative
Symptoms
Amnesia
1.Inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be
explained by normal forgetfulness.

2.The disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue,
posttraumatic stress disorder (PTSD), acute stress disorder, or somatization disorder.

3.Does not result from the direct physiological effects of a substance or a neurological or other general medical
condition.

4.This disturbance can be based on neurobiological changes in the brain caused by traumatic stress
 Duration and Intensity
• Onset of generalized amnesia is usually sudden. Less is known about the onset of
localized and selective amnesias because these amnesias are seldom evident, even to the
individual. Although overwhelming or intolerable events typically precede localized amnesia,
its onset may be delayed for hours, days, or longer.

• Individuals may report multiple episodes of dissociative amnesia. A single episode may
predispose to future episodes. In between episodes of amnesia, the individual may or may not
appear to be acutely symptomatic. The duration of the forgotten events can range from
minutes to decades.
 Risk Factors
1. Trauma caused by human assault rather than natural disaster
2. Repeated traumatization as opposed to single traumatic events
3. Longer duration of trauma
4. Fear of death or significant harm during trauma
5. Trauma caused by multiple perpetrators
6. Close relationship between perpetrator and victim
7. Betrayal by a caretaker as part of abuse
8. Threats of death or significant harm by perpetrator if the victim discloses his or her
identity or information regarding the traumatic experience
 Prognosis
• Acute dissociative amnesia frequently spontaneously resolves once the person is removed to safety
from traumatic or overwhelming circumstances.

• Some patients do develop chronic forms of generalized, continuous, or severe localized amnesia and
are profoundly disabled and require high levels of social support, such as nursing home placement or
intensive family caretaking.

• Clinicians should try to restore patients' lost memories to consciousness as soon as possible;
otherwise, the repressed memory may form a nucleus in the unconscious mind around which future
amnestic episodes may develop.
 Differential Diagnosis
• Dissociative identity disorder. Individuals with dissociative amnesia may report depersonalization and auto-
hypnotic symptoms. Individuals with dissociative identity disorder report pervasive discontinuities in sense of self
and agency, accompanied by many other dissociative symptoms.
• Posttraumatic stress disorder. Some individuals with PTSD cannot recall part or all of a specific traumatic event.
• Neurocognitive disorders. In neurocognitive disorders, memory loss for personal information is usually embedded
in cognitive, linguistic, affective, attentional, and behavioral disturbances.
• Substance-related disorders. In the context of repeated intoxication with alcohol or other substances/medications,
there may be episodes of "black outs" or periods for which the individual has no memory.
• Catatonic stupor. Mutism in catatonic stupor may suggest dissociative amnesia, but failure of recall is absent.
Other catatonic symptoms (e.g., rigidity, posturing, negativism) are usually present.
• Normal and age-related changes in memory. Memory decrements in major and mild neurocognitive disorders
differ from those of dissociative amnesia, which are usually associated with stressful events and are more specific,
extensive, and/or complex.
 Comorbidity
 Many individuals with dissociative amnesia develop PTSD at some point during their life, especially
when the traumatic antecedents of their amnesia are brought into conscious awareness.

 Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a comorbid
somatic symptom or related disorder (and vice versa), including somatic symptom disorder and
conversion disorder (functional neurological symptom disorder).

 Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a
personality disorder, especially dependent, avoidant, and borderline.
 Dissociative Identity Disorder
(DID)
 Two or more distinct and fully developed personalities (alters)

 Each has unique modes of being, thinking, feeling, acting, memories, and relationships
 Primary alter may be unaware of existence of other alters

 Most severe of dissociative disorders

 Recovery may be less complete

 Typical onset in childhood

 Rarely diagnosed until adulthood

 More common in women than men

 Often comorbid with:

 PTSD, major depression, somatic symptoms

 Has no relation to schizophrenia

 No thought disorders or behavioral disorganization
 DSM-5 CRITERIA FOR Dissociative Identity
Disorder (DID)
Disruption of identity characterized by two or more distinct personality states (alters) or an experience of possession, as
evidenced by discontinuities in sense of self as reflected in altered cognition, behavior, affect, perceptions, consciousness,
memories, or sensory-motor functioning. This disruption may be observed by others or reported by the patient.

Recurrent gaps in recalling events or important personal information that are beyond ordinary forgetting

Symptoms are not part of a broadly accepted cultural or religious practice

Symptoms are not due to drugs or a medical condition

In children, symptoms are not better explained by an imaginary playmate or by fantasy play
 Dissociative Identity Disorder (DID)
Epidemiology
 No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006)
 Major increases in rates since 1970s

DSM-III (1980)
 Diagnostic criteria more explicit

Appearance of DID in popular culture

 Sybil
 The Three Faces of Eve
 Book and movie received much attention
 Etiology Of Dissociative Identity Disorder
(DID):
 Posttraumatic Model
Two Major Theories
 DID results from severe psychological and/or sexual abuse in childhood
 Because it is so rare, no prospective studies have been conducted

 Sociocognitive Model
 DID a form of role-play in suggestible individuals
 Could be iatrogenic—occurs in response to prompting by therapists or media
 No conscious deception

 Evidence raised in theory debate

 DID can be role-played
 Hypnotized students prompted to reveal alters did so (Spanos, Weekes, & Bertrand, 1985)
 DID patients show only partial implicit memory deficits
 Alters “share” memories (Huntjen et al., 2003)
 DID diagnosis differs by clinician
 A few clinicians diagnose the majority of DID cases
 For many, symptoms emerge after therapy begins
 Dissociative Identity
Disorder
Symptoms
1.Depression
2.Self- mutilation
3.Frequent suicidal ideation and attempts
4.Moodiness
5.Erratic behavior
6.Headaches
7.Hallucination
8.Substance abuse
9.Post traumatic symptoms
 Duration and Intensity
• DID appears to have a fluctuating clinical course that tends to be chronic and recurrent

• The average time period from first symptom presentation to diagnosis is 6-7 years
• Episodic and continuous courses have both been described

• The disorder may become less manifest as individuals age beyond their late 40s, but may reemerge during
episodes of stress or trauma or with substance abuse

Risk Factors
• Dissociative identity disorder is strongly linked to severe experiences of early childhood trauma, usually maltreatment.
• Physical and sexual abuse are the most frequently reported sources of childhood trauma.
• The contribution of genetic factors is only now being systematically assessed, but preliminary studies have not found
evidence of a significant genetic contribution.
 Differential Diagnosis
• Major depressive disorder. Individuals with dissociative identity disorder are often depressed, and their symptoms
may appear to meet the criteria for a major depressive episode.
• Bipolar disorders. Individuals with dissociative identity disorder are often misdiagnosed with a bipolar disorder,
most often bipolar II disorder.
• Posttraumatic stress disorder. Some traumatized individuals have both posttraumatic stress disorder (PTSD) and
dissociative identity disorder. Accordingly, it is crucial to distinguish between individuals with PTSD only and
individuals who have both PTSD and dissociative identity disorder.
• Psychotic disorders. Dissociative identity disorder may be confused with schizophrenia or other psychotic disorders. The
personified, internally communicative inner voices of dissociative identity disorder, especially of a childmay be mistaken
for psychotic hallucinations.
• Personality disorders. Individuals with dissociative identity disorder often present identities that appear to encapsulate a
variety of severe personality disorder features, suggesting a differential diagnosis of personality disorder, especially of tiie
borderline type.
 Comorbidity
Individuals with dissociative identity disorder usually exhibit a large number of comorbid disorders. In particular, most develop PTSD.
Other disorders that are highly comorbid with dissociative identity disorder include depressive disorders, trauma- and stressor-
related disorders, personality disorders (especially avoidant and borderline personality disorders), conversion disorder
(functional neurological symptom disorder), somatic symptom disorder, eating disorders, substance-related disorders,
obsessive compulsive disorder, and sleep disorders. Dissociative alterations in identity, memory, and consciousness may affect
the symptom presentation of comorbid disorders.

Treatment of Dissociative Identity Disorder (DID

 Most treatments involve:
 Empathic and supportive therapist
 Integration of alters into one fully functioning individual
 Improvement of coping skills

 Psychodynamic approach adds:

 Overcome repression
 Use of hypnosis
 Age regression
 Can actually worsen symptoms